Clinical evaluation of a patient's upper extremities, and more particularly the hands, for disability can be a time-consuming process for skilled therapists and physicians. Because of the unique complexity of the hands' movements, multiple measurements must be taken across all joints of the fingers to determine their maximum angle of flexion and extension. There are fourteen joints or knuckles in a normal hand, and each of these must be measured in flexion and extension to arrive at a measure of the disability of the hand as is often required for proper clinical evaluation and for the patient to obtain compensation for an injury which has limited his range of motion. At present, a therapist must sit with a patient and manually measure each individual angle of flexion and extension for each joint with a goniometer by isolating the joint, aligning it with the legs of the goniometer, and manually recording the measured included angle. Not only is this process tedious and time-consuming, and thus expensive to perform, but less time remains for the therapist to perform physical therapy with the patient. During the course of a patient's treatment, it is desirable to repeat these measurements over the time course of therapy to assess a patient's progress. Unfortunately, because there is some subjective element in the use of the goniometer and the current standard technique used in making hand function measurements, the repeatability of any particular examination is relatively poor. The variance of measurements from therapist to therapist has been so large with the standard goniometer so that the same therapist should measure the same patients each evaluation session. This is often not possible in a busy therapy center. This leads to uncertainty and ineffectiveness in assessing the patient's functional status and in designing treatment protocols.
Some attention has been paid in the prior art to the problem of evaluating and measuring the range of motion in the knee. Examples of these are found in U.S. Pat. Nos. 4,549,555 and 4,571,834. These references both contain the same disclosure relating to a knee laxity evaluator comprised of an instrumented seat, a restraint for restraining the thigh of the patient to the instrumented seat, a motion module consisting of a mechanical coupling extending between the seat and the patient's leg with a number of electromechanical rotary transducers for measuring the relative position of the leg, and a processor for analyzing the outputs of the seat and the motion modules to provide an indication of applied force and relative motion of the knee. The device disclosed is mechanically and operationally complex and is limited in its accuracy although it is probably adequate as measuring knee motion of a knee joint which is a very large joint whereas measuring finger motion requires much more delicate instrumentation.
Perhaps because of the bulky, mechanically complex construction of the device disclosed in these prior patents, the inventors herein are aware of a later commercial model of this device which is adapted for use with the spine which is comprised of a wand mounted at the end of a multi-jointed mechanical arm, the arm being adjustably mounted to a pole stand and having a rotary transducer at each of the joints of the arm. Apparently, a foot switch is also provided and the device is understood to be used by tracing an exterior outline corresponding to the perceived position of posterior elements and spinous processes in the spine with the wand as the foot switch is operated to input data corresponding to the shape of the spine to a computer which then performs an analysis including flexibilty and range of motion measurement. However, as with the prior art device disclosed in the patents mentioned above, the overall accuracy is limited by the use of the three rotary mono-angular (mono-articulated) single DOF transducers in the multi-jointed extension arm which are believed to generate only relative position data obtained by integrating a plurality of measurements over time, although the level of accuracy attainable is probably more than adequate for the measurement of the posterior elements of the dossal and lumbar spine.
The inventors herein are also aware of a prior art device consisting of a "data glove" as is described generally in U.S. Pat. No. 4,542,291 and also in a Scientific American magazine article appearing on the cover and within the October 1987 issue. This device is essentially comprised of a glove which is slipped onto and encloses the hand and which contains a plurality of fiber-optic cables anchored at both ends to an interface board which run the length of each finger and doubles back. As the hand is measured, it is not visible to the operator. Each cable has a light-emitting diode at one end and a phototransistor at the other with the cables being treated so that light escapes when a finger flexes. Thus, a change in the amount of light received by the phototransistor, when converted into an electrical signal, is directly representative of a change in position or flexion of the finger such that the data glove can measure relative movement of the finger as it is flexed or extended. Additionally, an absolute position and orientation sensor is mounted near the wrist of the glove to provide a single absolute point of reference for the entire hand, although it does not provide data as to the position or angle of flexion or extension of any of the fingers themselves. The data glove provides simultaneous real time measurements concerning the relative motion or movement of the fingers but does not provide data corresponding to the absolute position of any of the fingers. Thus, to measure an angle of maximum flexion at each joint, the finger must first be placed in a known position and then the finger flexed to its position of maximum flexion as the output of the data glove is continuously monitored. The maximum angle of flexion may then be determined by comparing this known starting position with the angle of flexion computed by integrating continuously recorded measurements. of course, there is some uncertainty in determining and repeating a known initial position and angle for a finger before it is flexed, especially if that finger is incapable of a full and complete range of motion. Once again, as with the prior art manual technique, and the rotary transducers of the prior art knee de vice, significant potential for error and subjectivity enter into the measurement of angles of flexion and extension with the data glove. There is no provision for competent human intervention in the operation of the data glove.
Still another problem in evaluating the hand is the complex nature of the wrist. Presently, in accepted standards of medical practice, the range of motion for the wrist is determined by having the patient grip a cylindrical object such as a pencil or the like, and holding the pencil in a vertical orientation which is defined as a neutral position. The patient is then told to rotate the pencil inwardly to its maximum extent and the angle is measured, and then to rotate the pencil outwardly to its maximum extent and that angle is measured as well. These angular measurements can then be used to determine the maximum pronation and supination. However, it is known that there is approximately 30.degree. of additional total rotation contained in the joints between the radius and ulna and the fingers such that these measurements are not the true measurements of the range of motion of the wrist. Thus, there exists no protocol or methodology in the prior art to properly fully evaluate the true range of motion of the wrist. Furthermore, none of the prior art devices discussed above are capable of generating data which accurately provides the range of motion for the wrist. This is partially due to the fact that it is difficult to visualize the radius and ulna as the wrist is rotated, and for the further reason that the prior art systems have errors of measurement which are significant in measuring the small distances which through the wrist rotates.
To solve these and other problems in the prior art, the inventors herein have succeeded in designing and developing an upper extremity evaluation system which is particularly adapted to and useful in measuring the range of flexion and extension of the joints of the hand, wrist and elbow and automatically calculating a degree of disability in accordance with American Medical Association (AMA) standards commonly used by the courts and workers compensation boards in determining the financial compensation due to a patient for an injury. In a distinct departure from the prior art, the inventors have succeeded in adapting a three-dimensional spatial absolute position and orientation sensor into a computer measurement system which permits the convenient collection of data by a therapist corresponding to the absolute position of the proximal and distal segments at a joint in the fully extended as well as the fully flexed position. In other words, a therapist can quickly and conveniently enter data automatically into the computer which corresponds to the position of the various joints of the patient's hand as the hand is manipulated into one of only several different positions and held for only a brief period of time therein. Because absolute position data is measured and collected, much greater accuracy is attainable. Furthermore, because of the convenient methodology used to collect the data, an evaluation is also capable of a high level of repeatability. This has a dramatic impact on the accuracy of the initial assessment given to a patient, as well as the evaluation of treatment protocols through the course of the patient's rehabilitation. Still another advantage with the inventors' system is that for the first time accurate range of motion information can be easily collected by measuring the exact location of the radial and ulna styloid processes while the wrist is held in the neutral, supinated, and pronated positions. The computer may then eliminate the translation of these bones as they are moved from the computation to arrive at a true and accurate measure of the wrist's range of motion. Further information may also be obtained relating to the range of supination and pronation at the metacarpal level, which provide additional functional information of interest to the surgeon. However, perhaps the greatest advantage of the device is that it dramatically reduces the amount of therapists' time required to perform the clinical evaluation, and virtually eliminates the hand surgeon's time in evaluating the therapists' results. This is all achieved while significantly increasing the reliability and variability of the results.
In addition to measuring the angles of maximum flexion and extension, a dynamometer and pinch gauge are also connected directly to the computer for the direct entry of data corresponding to the grip strength and pinching strength of the hand and fingers. Still further data may be taken corresponding to other measurements, such as sensitivity, through the keyboard provided with the computer. Thus, the upper extremity evaluation system of the present invention permits a therapist to make an evaluation of any of the upper extremities, to input data gained through subjective manual measurements, and to permit such desired manipulation and calculation of the data to arrive at a degree of disability in accordance with AMA standards.
Briefly, the protocol for entering data corresponding to the hand includes locating twenty-four specific points on the dorsal surface of the hand in a sequence which permits the most rapid data collection as well as to give maximum flexion values. This begins with the four points on the fully flexed thumb, taken in a proximal to distal fashion, thus measuring the metacarpal phalangeal (MP) and interphalangeal (IP) joints. Then, with the fingers maximally flexed in a fist and the thumb abducted, the first four points on the remaining digits are digitized, again proximal to distal, one digit at a time, beginning with the index finger and moving ulnarly. These four points correspond to a mid-thumb metacarpal, MP apex, IP apex, and thumb nail for the thumb. For each digit, five points correspond to the midmetacarpal, MP apex, proximal interphalangeal (PIP) apex, distal interphalangeal (DIP) apex, and fingernail. The first four points are digitized. This measures the MP and PIP joints. For the DIP joint, the fingers are extended at the MP joints and flexed at the PIP and DIP joints. Using the same digit order, the third, fourth and fifth points are redigitized. As can be appreciated, this protocol can be routinely performed by an average therapist in less than two minutes. Data entry is achieved by touching the finger or hand with a wand or pointer, and pressing a foot switch when the wand or pointer is in the appropriate and desired location. This permits the therapist to choose the point in time for data entry to provide greater control over the evaluation.
A software package which operates on the control desktop personal microcomputer has been designed and developed by the inventors which guides and instructs the therapist as he/she proceeds through the evaluation process. This ensures a complete examination taken with the same methodology and helps improve the accuracy of results. In the prior art, significant inconsistencies of results are often noticed between therapists examining the same patient. With the present invention, these inconsistencies are thought to be significantly reduced. Furthermore, the software calculates angles of flexion and extension from the position data entered by the therapist and makes further calculations in accordance with AMA standards to arrive at the degree of disability. A hand surgeon may then review these results and verify them in accordance with accepted medical practice. However, because of the increased reliability brought to the measurement and data entry portions of the evaluation, the amount of time and involvement of the hand surgeon can be significantly reduced thereby significantly reducing the cost of the evaluation to the patient while improving the results obtained thereby.
While the principal advantages and features of the present invention have been briefly described, a fuller understanding may be attained by referring to the drawings and description of the preferred embodiment which follow.